🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-05-31 11:38:50

Transcript

[00:00 → 00:04] Doctor, good morning, Mrs. Sharma. It's good to see you again.
[00:05 → 00:08] How have you been feeling since our last session?
[00:09 → 00:16] Patient, good morning, doctor. Honestly, not great. The pain in my left hand has gotten worse.
[00:17 → 00:22] It's sharp, constant, and sometimes it feels like it's burning from the inside.
[00:22 → 00:28] And I don't know how to say this. I've started seeing things that aren't there.
[00:29 → 00:31] Doctor, I'm really sorry to hear that.
[00:32 → 00:34] Let's take things one at a time.
[00:35 → 00:39] About the hand pain that's likely due to nerve involvement from the cancer spreading.
[00:39 → 00:43] I'll adjust your pain medication and add a nerve pain reliever.
[00:44 → 00:47] Something like gabapentin may help ease that burning sensation.
[00:48 → 00:52] Patient, thank you. That pain has been unbearable at times.
[00:53 → 00:55] Doctor, I can imagine.
[00:55 → 00:59] Now, about the hallucinations are you seeing or hearing things?
[01:00 → 01:01] And how often does it happen?
[01:02 → 01:04] Patient, mostly at night.
[01:05 → 01:08] I sometimes see people in my room or hear voices calling my name.
[01:09 → 01:12] I know they're not real, but it's terrifying.
[01:13 → 01:15] Doctor, that sounds distressing.
[01:16 → 01:20] It could be a side effect of the high dose opioids or just the progression of the illness.
[01:21 → 01:24] I'll refer you to our palliative care psychiatrist.
[01:25 → 01:30] Meanwhile, I'll reduce your opioids slightly and introduce a low dose of halopiridol.
[01:30 → 01:32] It should help manage the hallucinations.
[01:33 → 01:38] Patient, thank you. Doctor, it's just been so hard.
[01:39 → 01:40] I feel like I'm losing control.
[01:41 → 01:44] Doctor, you're not alone, Mrs. Sharma.
[01:45 → 01:47] We're here to support you every step of the way.
[01:48 → 01:53] We'll keep monitoring and adjusting things to give you as much comfort and peace as possible.
[01:53 → 01:56] Patient, I'm grateful for that, really.

Clinical Notes

Subjective

  • Patient: Mrs. Sharma.

  • Primary Concern:

  • Experiencing worsening sharp, constant pain in the left hand, sometimes with a burning sensation.
  • Reports visual and auditory hallucinations, mostly at night, seeing people in the room and hearing voices calling her name.

Objective

  • Medical History:
  • Cancer with suspected nerve involvement.
  • High dose opioids.

Assessment

  1. Pain Management:
  2. Likely due to nerve involvement from cancer spreading.

  3. Adjust pain medication and add a nerve pain reliever like gabapentin.

  4. Hallucinations:

  5. Possibly a side effect of high dose opioids or disease progression.
  6. Referral to palliative care psychiatrist.
  7. Introduce low-dose haloperidol to manage hallucinations.

Plan

  1. Medication Adjustment:
  2. Adjust pain medication to manage hand pain.
  3. Introduce gabapentin for nerve pain.

  4. Reduce opioids slightly and start low-dose haloperidol for hallucinations.

  5. Psychiatric Referral:

  6. Refer to palliative care psychiatrist for further evaluation and management of hallucinations.

  7. Support and Monitoring:

  8. Ensure continuous monitoring and adjustments to provide comfort and support.
  9. Emphasize ongoing support throughout the treatment process.
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